“TASB, It’s a Medical Only Claim. Don’t Call Us, We’ll Call You”

by Sarita Shipe

The Fund is classified by the Texas Department of Insurance Division of Workers’ Compensation (DWC) as a “High Performer” among carriers in the delivery of benefits. However, a late payment of weekly benefits to an injured worker does occur from time to time, and this can be problematic when it happens.

Medical Only claims count for the majority of total workers’ compensation claims submitted by districts. Most of these claims result in no lost time. Once reported, you don’t expect a follow-up phone call from us just to confirm what you’ve already reported. 

Our internal audits have demonstrated however, that one of the main reasons a late payment happens is because the employee is actually losing time as a result of the Medical Only injury that was reported. Since there can be many reasons within a district why lost time information does not filter down to the person filing the First Report of Injury, the Fund has adopted the policy of contacting the injured employee upon receipt of the Medical Only claim. If our numerous attempts are unsuccessful, the adjuster will contact the person completing the First Report of Injury to verify the employee is still on the job. We hope this practice will not be bothersome to you. We can assure you,  there are good reasons behind it.  

First we must consider the negative impact to an injured employee who is off work, suffering the physical effects of an injury and is temporarily without income. To him or her, time and accurate reporting is of the essence.  Another consideration is the potential fine that can be assessed by DWC to the Fund if lost time is discovered too late and weekly benefits are not initiated timely. The maximum fine for late benefits can be up to $25,000 for each day in which the payment is late. 

So, the next time your phone rings and the adjuster is on the line to confirm that there is no lost time on your Medical Only claims, please excuse the inconvenience. We remain committed to protecting you and making sure that your injured workers receive the timely benefits they are owed.